Destructive arthritis of the wrist and palmoplantar pustulosis.

The authors report a case of destructive arthritis of the right wrist occurring in a 29-year-old Algerian man, associated with palmoplantar pustulosis and HLA B27 antigen. Joint fluid and synovial biopsy were sterile and the course was favourable with surgical synovectomy and nonsteroidal antiinflammatory drugs. Usually, arthritis associated with palmoplantar pustulosis is of the non-erosive type but cases of destructive arthritis have been reported. This condition is probably a new member of the seronegative spondylarthropathy group.

A definite case of spondylodiscitis caused by Streptococcus equisimilis.

To shed light on the role of Streptococcus equisimilis (SE) in the pathogenesis of intervertebral disc infection, we report here a case of lumbar spondylodiscitis in a 37-year-old male caused by SE, with identification of this strain by cultures from L4-L5 lumbar disc biopsy. Intravenous therapy with penicillin and gentamycin combined with immobilization resulted in a rapid and complete recovery. The patient did not have underlying disease and showed no obvious history of exposure to animals. We conclude that SE may be responsible for both septic arthritis and spondylodiscitis.

Schnitzler's syndrome (urticaria and macroglobulinemia) dramatically improved with corticosteroids.

The authors report the case of a 65-year-old man who had an evolving case of Schnitzler's syndrome with lytic bone lesions which was unresponsive to several drugs, and which dramatically improved with small quantities of corticosteroids. Schnitzler's syndrome, first described in 1974, is defined by chronic non-pruritic urticaria, osteocondensation, and monoclonal IgM dysproteinemia without features of lymphoproliferative disease, and is associated with fever, deterioration of the general health and biological signs of inflammation. Only 22 cases of Schnitzler's syndrome have been reported hitherto and there is no known effective treatment, H1 and H2 blockers, dapsone, colchicine, chloroquine, cyclophosphamide, chlorambucil and azathioprine having proven useless in the few patients treated. Corticosteroids may be effective, however, especially against the urticaria.

[Neuromeningeal sites of multiple myeloma: 3 cases and review of the literature]. / Localisations neuroméningées du myélome multiple: trois observations et revue de la littérature.

Neurologic manifestations are not unusual in multiple myeloma. Conversely meningeal and cerebral involvement have been very rarely reported. We report here on three patients with multiple myeloma and meningeal or cerebral involvement (two of them with autopsy study): one case of cerebellar involvement associated with secondary plasma cell leukemia and two cases of meningeal involvement. We reviewed the characteristics of 20 cases of meningeal involvement with demonstration of plasma cells at cerebrospinal fluid analysis (18 previously reported cases and our two patients). Meningeal involvement occurs in patients with initially stage III multiple myeloma in 85% of cases and is associated with the occurrence of plasma cell leukemia in 20% of cases. The most frequent neurologic signs are: confusion (60%), altered consciousness (25%), gait disorder (25%), cranial nerve palsy (25%). Meningismus is rarely present. Diagnosis is based on cerebrospinal fluid analysis after lumbar puncture which should be made after cranial magnetic resonance imaging. The diagnosis of intra-cranial haemorrhage and infectious meningitis have to be cautiously ruled out. Despite treatments (systemic and/or intrathecal chemotherapy, radiation therapy), prognosis is very poor: mean time of survival after the occurrence of neurologic signs is about 2 months.

Polyarthritis with perinuclear antineutrophil cytoplasmic antibody inaugurating microscopic polyangiitis. Report of a case.

Microscopic polyangiitis, a condition recently differentiated from macroscopic periarteritis nodosa, is characterized by small vessel damage, pauciimmune necrotizing glomerulonephritis and presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). Arthralgia is a common symptom often present early in the disease, and other joint manifestations have also been reported. We report a case with polyarthritis as the first manifestation. Perinuclear ANCA was found in a moderate titer. A renal biopsy done six months after the onset of joint symptoms to investigate rapidly progressive renal failure established the diagnosis. The p-ANCA exhibited antimyeloperoxidase specificity. In the discussion we review the diagnosis of microscopic polyangiitis and of concomitant polyarthritis and p-ANCA production. ANCA is present in some patients with rheumatoid arthritis or systemic lupus erythematosus. It is important to determine the specificity of the ANCA since presence of p-ANCA with antimyeloperoxidase specificity in a patient with polyarthritis is highly suggestive of systemic vasculitis.

Hypersensitivity to glucocorticoids: does it exist?

Hypersensitivity to corticosteroids is a classical but rarely reported event. We report a 30-year-old patient who developed generalized urticaria after her first methylprednisolone bolus. We reviewed the relevant literature to look for factors associated with hypersensitivity to corticosteroids. Causality should be evaluated on a case-by-case basis using diagnostic criteria for drug hypersensitivity reaction. Etiopathogenesis may involve either an IgE-mediated immunoallergic reaction or semi-delayed hypersensitivity. The main problems are identification of the offending agent and evaluation of the safety of further corticosteroid therapy. Although a few fatal reactions have been reported, some were probably due to underlying cardiovascular disease or serum electrolyte abnormalities.